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psnet.ahrq.gov/issue/care-quality-patient-safety-and-nurse-outcomes-hospitals-serving-economically-disadvantaged
December 09, 2020 - Study
Care quality, patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for investment in nursing.
Citation Text:
Viscardi MK, French R, Brom H, et al. Care quality, patient safety, and nurse outcomes at hospitals serving economically disad…
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psnet.ahrq.gov/issue/evaluation-second-victim-peer-support-program-perceptions-second-victim-experiences-and
December 23, 2020 - Study
Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST).
Citation Text:
Finney RE, Czinski S, Fjerstad K, et al. Evaluation …
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psnet.ahrq.gov/issue/weekend-specialist-intensity-and-admission-mortality-acute-hospital-trusts-england-cross
November 25, 2020 - Study
Classic
Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study.
Citation Text:
Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in E…
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psnet.ahrq.gov/issue/weekly-variation-health-care-quality-day-and-time-admission-nationwide-registry-based
September 24, 2014 - Study
Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.
Citation Text:
Bray BD, Cloud GC, James MA, et al. Weekly variation in health-care quality by day and time of admission: a nationwide, …
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psnet.ahrq.gov/issue/improving-transfusion-safety-operating-room-barcode-scanning-system-designed-specifically
February 01, 2023 - Study
Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis.
Citation Text:
Vanneman MW, Balakrishna A, Lang AL, et al. Impro…
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psnet.ahrq.gov/issue/accreditation-council-graduate-medical-educations-limits-residents-work-hours-and-patient
July 10, 2008 - Study
Classic
The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety.
Citation Text:
Jagsi R, Weinstein DF, Shapiro J, et al. The Accreditation Council for Graduate Medical Education's limits on residents'…
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psnet.ahrq.gov/issue/assessing-state-safe-medication-practices-using-ismp-medication-safety-self-assessment
March 02, 2016 - Study
Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.
Citation Text:
Vaida AJ, Lamis RL, Smetzer JL, et al. Assessing the State of Safe Medication Practices Using the ISMP Medication Safety Self Assessment ® …
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psnet.ahrq.gov/issue/use-prescribing-safety-quality-improvement-reports-uk-general-practices-qualitative
December 08, 2021 - Study
Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment.
Citation Text:
Khan NF, Booth HP, Myles P, et al. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. BMC Health Serv Res. 2…
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psnet.ahrq.gov/issue/implementing-computerized-provider-order-entry-existing-clinical-information-system
October 19, 2022 - Study
Implementing computerized provider order entry with an existing clinical information system.
Citation Text:
Barron WM, Reed L, Forsythe S, et al. Implementing computerized provider order entry with an existing clinical information system. Jt Comm J Qual Patient Saf. 2006;32(9):506-…
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psnet.ahrq.gov/issue/missed-nursing-care-surgical-care-hazard-patient-safety-quantitative-study-within-incharge
July 12, 2023 - Study
Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme.
Citation Text:
Edfeldt K, Nyholm L, Jangland E, et al. Missed nursing care in surgical care– a hazard to patient safety: a quantitative study within the inCHARGE pr…
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psnet.ahrq.gov/issue/central-venous-catheter-guidewire-retention-lessons-englands-never-event-database
September 15, 2021 - Study
Central venous catheter guidewire retention: lessons from England's never event database.
Citation Text:
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10…
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psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals
June 23, 2010 - Study
Integration of prospective and retrospective methods for risk analysis in hospitals.
Citation Text:
Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):42…
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psnet.ahrq.gov/issue/identifying-and-categorising-patient-safety-hazards-cardiovascular-operating-rooms-using
August 25, 2015 - Study
Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.
Citation Text:
Gurses AP, Kim G, Martinez EA, et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms u…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
February 01, 2010 - Spotlight Case July 2008
Spotlight Case
Adolescent Diabetes:
A Routine Visit?
Source and Credits
This presentation is based on the February 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Gail B. Slap, MD, MSc, Children’s Hospital of P…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/33813/psn-pdf
August 01, 2016 - Safety In Dentistry
August 1, 2016
Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/safety-dentistry
Perspective
In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell
tortures Babe Levy (played by…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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